Documentation Of In-Office Imaging

Upon performing reviews of colleagues’ documentation practices, one consistent deficiency I find is the documentation that accompanies in-office imaging, namely X-ray and ultrasound studies. Each payer may have their own guidelines, but most follow the guidelines promulgated by Medicare in the Medicare Benefit Policy Manual, Chapter 15, Section 80.

These guidelines include the requirement of a written order in the medical record for the imaging study. This order must include … read more